Review: “Empire of the Scalpel,” by Ira Rutkow

As Rutkow observes at the beginning of his book, it is a “reasonable certainty that no one in the industrialized world will escape having an illness for which effective treatment requires a surgical operation.” I myself would probably be blind in at least one eye (from retinal detachments), walk with a limp (from a complex ankle fracture) and possibly be dead (from urosepsis) if not for the help of my surgical colleagues. Yet until 150 years ago, as Rutkow explains, surgery was limited to the external parts of the human body, such as amputations for trauma. The only internal surgery was the occasional foray into the bladder for bladder stones and trepanning of the skull. Indeed, skulls have been found all over the planet, dating back thousands of years, with deliberately made holes that had healed over with new bone, meaning that the patient survived the procedure. But it is anybody’s guess as to whether the earliest trepanning was done to release a traumatic blood clot from inside the skull, or to release an evil spirit responsible for epilepsy or some similar, misunderstood disorder.

As Rutkow writes, the emergence of surgery from its barbaric past rested on four pillars — the understanding of anatomy, the control of bleeding, anesthesia and antisepsis. The story, however, is not one of steady, rational progress. The surgeon Galen, working in the second century A.D., wrote extensively on anatomy; some of his experience came from treating wounded gladiators but much of it was based on dissecting animals, and was simply wrong with respect to human anatomy. His writings were passed down by the Andalusian physician Abu al-Qasim al-Zahrawi, among others, to become dogma in the Middle Ages.

The first breakthrough came more than a thousand years later with the Renaissance, and the relaxation of taboos about dissecting the dead. The Flemish physician Andreas Vesalius, the greatest of the early anatomists, carried out his dissections on the corpses of executed criminals, often removed surreptitiously from the gallows at night. Surgeons such as Ambroise Paré in France, working on battlefield injuries, established ways of controlling bleeding — tying off blood vessels, for instance, rather than using red-hot irons and plunging the stump of an amputated limb into boiling oil.

But the greatest change came in the mid-19th century, with the use of ether as an anesthetic, and Joseph Lister’s work on antisepsis. This was based on Louis Pasteur’s work showing that infection was caused by living microbes, and not (as had been previously thought) by smells and foul air. And yet, as the medical historian David Wootton has pointed out in his book “Bad Medicine,” the Swiss physician Paracelsus was using ether to anesthetize chickens in the 16th century and Antonie van Leeuwenhoek had discovered bacteria, using a microscope of his own making (although of rather an awkward design), in the 17th century. The German Hungarian obstetrician Ignaz Semmelweis showed that hand-washing made a massive difference to the incidence of fatal postnatal infections in women. This was 20 years before Lister’s and Pasteur’s work, yet Semmelweis was dismissed by his colleagues and he died in obscurity. The history of surgery, especially until the modern era, is as much about doctors’ innate conservatism as it is about innovation.

It is, however, ultimately a history of triumphant progress — although not without dark episodes, such as the abuse of psychosurgery in the middle of the 20th century.